VIEWS: 292 PAGES: 63 POSTED ON: 5/9/2010
2007 Skin Safety Class Agenda: 1. History on Pressure Ulcers 2. Prevention 3. Communication 4. Treatment Options 5. Competency Pressure Ulcers: 2003: Adverse Health Care Event Reporting Law went into effect. Dec 6, 2004: Full reporting of events was expected. 1st year data: #1: Foreign objects left in pts #2: Stage 3-4 pressure ulcers 2nd year data: #1: Stage 3-4 pressure ulcers 3rd year data: #1: Stage 3-4 pressure ulcers Joint Commission Standards for Long Term Care FAQs for the 2006 National Patient Safety Goals for Long Term Care (Updated 2/06) Goal 14 (Pressure ulcer prevention) [New—14A] How should staff assess the risk of a resident developing a pressure ulcer? [New—14A] What are some actions staff can take to prevent pressure ulcers in high risk residents? More coming for acute care hospitals Public Advocacy Groups Pressure Ulcers are “mostly” Preventable Prevention is the key!! 1. Know what causes pressure ulcers 2. Know the patient’s risks 3. Provide prevention interventions 4. Communication of interventions 5. Treatment plans MN Alliance of Patient Safety (MAPS) Advice to Hospitals: November 10, 2005 Pressure Ulcer Prevention Summit Recommendations: ICSI Guidelines on Pressure Ulcers Health Care Protocols on Risk Assessment and Prevention Skin Care Teams Vision of a Skin Team Energetic leaders: Beth Kaiser Schafer, MS, RN Director of Professional Practice Mary Murphy, MA, RN Accreditation Coordinator Literature review of best practice for skin care. Review ICSI recommendations. Review NDNQI recommendations. Who is setting standard now? Partner with plastic surgeons Separate burns and surgical incisions Create education for the team. Get leadership support. Invite the right players to the team. Must have an interest or passion! Skin Safety Team Begins 12/9/05 Team Members: Physicians Administrative sponsor Clinical Educators Nutrition Director of PT/OT Nursing Managers Nursing Head Nurses Performance Improvement Respiratory Therapy Many staff nurses Ad hoc: Product manager Ad hoc: Electronic Medical Records staff member Skin Safety Team Begins 12/9/05 Team Members: Dr. Andrew Kiragu, Pediatrics Dr. John Bower, Knapp Rehab Beth Schafer, Administration Mary Murphy, CE Float Pool Barb Gale, CE Pediatrics Ann Kallinger, CE 5 Medicine Sallie Konruff, Nutrition Ruth Gromek, PT/OT Laura Miller, Nurse Mgr, MICU Terri Peterson, Head Nurse, MICU Karen Hoybook, PI Tomi Berntsen, Respiratory Skin Safety Team Begins 12/9/05 Team Members: Pat Anderson, Staff RN, Burn Sheri Wacha, Staff RN, Ortho Sarah Chown, Staff RN, STN Alicia Decker, Staff RN, SICU Scott Church, Staff RN, SICU Dan Rogich, Staff RN, MICU Darrel Waltz, Staff RN, 5 Med Ad Hoc: Mary Peloquin, EMR Sue Winkler, Product Manager Member Education (Dec-Feb) 1st HCMC Skin Team Meeting 12/9/06 All members attended skin class Class is based on best practice and ICSI guidelines. Focused on Risk assessments Prevention strategies Language of wounds Standardized treatment strategies Standardized assessments Skin Safety Team Deliverables Establish baseline data. Reduce the incidence of skin pressure ulcers by 20%. Assess the knowledge base of the staff and reassess after six months. Submit ongoing data to the NDNQI beginning in the first quarter of 2006. Assist in standardizing skin care across the organization. Determine cost savings related to improved care (ROI). Take a leading role in the standardizing of language for documentation in the (EHR). Results (2006) Pressure Ulcers 60 50 # of ulcers 40 Stage 1 30 Stage 2 20 Stage 3 10 0 Feb March April May July Aug Sept Oct Month 57% reduction hospital wide 75% reduction in stage 2 ulcers on SICU Class Objectives Define a pressure ulcer List four underlying causes associated with pressure ulcers. Describe the standard for completing a skin risk assessment. Identify interventions use in preventing pressure ulcers. Describe a proper skin inspection. Identify language for documentation of a wound assessment. Define the stages for classifying pressure ulcers. Describe appropriate products for wound treatment. What is a Pressure Ulcer? Localized areas of tissue destruction caused by compression of soft tissue over bony prominence and an external surface for prolonged period of time. Causes of Skin Damage: Pressure, Shear, Friction, Moisture Pressure: Pressure is created when the external surface against the skin and the person’s skeleton compress soft tissue sufficiently to interrupt circulation to the skin. When circulation is interrupted long enough, tissue ischemia and tissue death occur. Causes of Skin Damage: Pressure, Shear, Friction, Moisture Pressure: The amount of pressure necessary to compress capillaries and interrupt circulation varies. Patients with disease processes, injury, those requiring vasopressors, or those with conditions resulting in impaired oxygenation or perfusion will require less pressure to create tissue ischemia, thus are more at risk. Causes of Skin Damage: Pressure, Shear, Friction, Moisture Causes of Skin Damage: Pressure, Shear, Friction, Moisture Shear: Shear is the interaction of gravity and friction causing twisting or kinking of blood vessels. Rather than completely interrupting blood flow, shear diminishes circulation to tissue and damages both tissue and blood vessel integrity. Shear occurs when the skeleton moves, but the skin remains fixed to an external surface. Causes of Skin Damage: Pressure, Shear, Friction, Moisture Examples of Shear: Pulling patient up in bed Patient in Fowler’s position who slides down in bed Slide patient from bed to stretcher. Shear and Friction Causes of Skin Damage: Pressure, Shear, Friction, Moisture Friction: Friction contributes to pressure ulcer formation by damaging the skin at the epidermal- dermal interface, the basement membrane. Friction ulcers are generally superficial and easily reversed, unless the cause is not removed. Causes of Skin Damage: Pressure, Shear, Friction, Moisture Examples of Friction: Heels and elbows which aid in movement for bedridden patients. Agitated patients or those experiencing seizures. Superficial abrasion or blistering Causes of Skin Damage: Pressure, Shear, Friction, Moisture Moisture: Moisture is a chemical cause of pressure ulcers. It weakens the cell wall of individual skin cells. It can also change the pH of the skin. Causes of Skin Damage: Pressure, Shear, Friction, Moisture Sources of moisture: Fecal and urinary incontinence, Wound drainage, Respiratory secretions, Emesis Perspiration Skin Safety: Risk Assessment ALL patients require a risk assessment at time of admission and every 24 hours. Factors Increasing Risk Advanced Age: decreased elastic fibers. More than 50% of pts with pressure sores >70 Decreased sensory perception Loss of feeling: need someone to look at feet Peripheral Vascular Disease Impaired Circulation Edema Vasoconstriction drugs MI/ Stroke,Trauma/fractures GI bleed Equipment Factors Increasing Risk Equipment: pneumoboots Spinal Cord injury: (Braces and stabilizing equipment) Neurological disorders Chronic medical conditions: diabetes, COPD, CHF History of pressure ulcers If have stage I, 10X greater risk of developing higher stage Preterm neonates Obesity/ Thin: 30 >BMI< 19 Factors Increasing Risk Critical Lab: Prealbumin level (reflects Visceral Protein Stores) Mild depletion = 10-15 Moderate depletion = 5-10 Severe depletion = < 5 Highest risk factors >70 years stroke impaired mobility pneumonia current smoking CHF low BMI fever altered mental state sepsis urinary and fecal hypotension incontinence dry and scaly skin malnutrition history of pressure restraints ulcers cancer anemia diabetes lymphopenia hypoalbuminemia Skin Safety: Risk Assessment Reassessment: Every 24 hours (Pressure ulcers can develop within 24 hours of insult or take as long as 5 days to present.) Change in condition (surgery, nutrition, level of mobility, etc) Skin Safety: Risk Assessment Tools: Braden scale for patients on the adult units. Braden Q scale for patients on the pediatric units. Braden Scale The Braden score is the total of the subcategory scores. Sensory Perception Moisture Activity Mobility Nutrition Friction and Shear Sensory Perception Defined as: The ability to respond meaningfully to pressure related discomfort. Score on scale of 1-4 1. Completely limited Unresponsive or inability to feel pain 2. Very limited Sensory impairment, moaning or restlessness 3. Slightly limited Some sensory impairment, can’t communicate need to be turned. 4. No limitations Has no sensory deficits Moisture Defined as: the degree to which skin is exposed to moisture. Score on scale of 1-4: 1. Constantly Moist Sweating, incontinent, noticed each time pt is turned or moved. 2. Moist Often moist, linen changed 1x/ shift 3. Occasionally moist Extra linen change 1x/day 4. Rarely moist Skin is usually dry, linen changed routinely Activity Defined as: the degree of physical activity. Score on scale of 1-4: 1. Bed fast Confined to the bed 2. Chair fast Ability to walk is almost non-existent, must be assisted into chair. 3. Walks occasionally Short distances, infrequent, most of time in bed or chair. 4. Walks frequently Walks outside of room 2x/day Walks inside of room q 2 hours. Mobility Defined as: the ability to change and control body position. Score on scale of 1-4 1. Completely immobile Not even slight changes in position 2. Very limited Occasional slight changes in position Not able to make significant change independently. 3. Slightly limited Makes frequent though slight changes 4. No limitations Makes major & frequent changes independently Nutrition Defined as “usual food intake pattern.” Score on scale of 1-4 1. Very poor Never eats complete meal Takes fluid poorly NPO/ IV fluids only >5 days 2. Probably inadequate Rarely eats a complete meal Occasionally will take supplement 3. Adequate Eats ½ of most meals Will take supplement if miss meals On TPN or adequate tube feedings 4. Excellent Eats every meal Does not require supplements Friction & Shear Score on scale of 1-3 1. Problem Requires max assist for moving Sliding against sheets is impossible Frequently slides down in bed Agitation leads to almost constant friction 2. Potential Problem Requires minimal assist for moving Skin slides to some extent on sheets Occasionally slides down in bed or chair 3. No apparent problem Moves independently Lifts up completely during move Maintains good position in bed or chair Braden Scoring Total scores for each subcategory. Max score is 23. Any score less < 4 (<3 for friction/shear) requires an intervention based on the subcategory. Refer to back of Braden Sheet for corresponding interventions. Place interventions on care plan. Interventions: Sensory Perception Minimize pressure for All patients Consider pressure relieving devices: Special bed: Matrix mattresses and Bari-beds Z-flow positioning pillows Increase mobility and activity status whenever possible. Minimally, turn patients every 2 hours Encourage weight shifting every 15 min in chair. Reposition every 1 hour if patient is unable to do it themselves. Prevent “Bottoming” Interventions: Mobility *Use lifts and hovermats with positioning. Turn q 1-2 hours Post turning schedule Encourage ambulating outside of the room at least BID. Interventions: Activity *Use lifts and hovermats with positioning. Position with pillows to elevate pressure points off of the bed. Consider physical therapy consult (MD) Interventions: Moisture Implement toileting schedule. Cleanse skin gently Do not use hot water Apply skin barrier after each cleansing Protect skin with duoderm Contain urine, stool, wound drainage, etc. Keep skin folds dry. Interventions: Friction & Shear Use transfer devices Use minimum of 2 people + draw sheet to pull pt up in bed. Don’t drag the patient Keep HOB at or < 30 degrees Use trapeze Pad skin surfaces (duoderm) (elbows/heels) Interventions: Nutrition Nutrition consult Offer nutrition supplements Monitor Nutrition intake. If NPO for > 24 hours, discuss plan with MD. Encourage family/friends to bring in favorite foods. Help patient get out of bed for meals. Skin Safety: Skin Inspection All Patients require full skin inspection upon admission: Inspect and palpate skin from head to toe. Skin Safety: Skin Inspection Ask patients about: Areas that lack sensation Areas of pain Location of previous ulcers (increases risk of new ulcer) Fragile skin, easy bruising Medications or medical condition putting patient at higher risk for breakdown, ie: steroids. Skin Safety: Skin Inspection Reassessment: Re-inspect and palpate ALL patients every 8- 24 hours. Re-inspect when transferring between units. Re-inspect after long procedures, ie: dialysis, MRI’s, etc. Skin Safety: Skin Inspection Examples of Ways to Integrate Inspection into Assessment: When applying O2; check the ears for pressure areas from tubing If patient is immobile; check the back of the head during repositioning. When doing lung sounds or turning; look over the back, shoulders and sacrum. When checking bowel sounds; look over skin folds and hips When placing pillows under calves; check heels and feet. When checking IV sites; check elbows and arms If patient is here for surgery; know the areas prone to breakdown. When getting patient up or doing cares; check the back, sacrum and heels. Skin Safety: Skin Inspection The Language of Wounds Measure wounds upon admission and weekly (or with significant changes). Note the location, size, depth, color of wound bed and surrounding tissue and describe the drainage. Skin Safety: Skin Inspection Size: Measure length, width and depth of wound. Measuring tools are available in unit storerooms. Describe wound as a clock with patient’s head at 12:00 and their feet at 6:00 to promote consistency in descriptions. Skin Safety: Skin Inspection Color of wound bed: Pale pink, pink (granulating tissue), red, yellow (slough), green (infection?) or black (necrotic tissue) Intact wound margins or evidence of undermining or tunneling. Describe the peri-wound skin also. (Warm or red may indicate infection. Maceration may indicate wound drainage is not managed. ) Percentage of granulation tissue present “75% necrotic tissue with 25% granulation tissue” Eschar Slough 59 Tunneling Tunneling Tunneling Periwound Skin Edema Induration Erythema Periwound Pain Maceration
"PPT - PowerPoint Presentation - Download Now PowerPoint"